Merck HPV Vaccine Patient Assistance Program

Because there is very little public funding for vaccinating adults in the United States, Merck pharmaceutical company established the Merck Vaccine Patient Assistance Program. You may be eligible for the program if all of the following apply:

• You live in the United States. (You do not have to be a U.S. citizen.)
• You are between the ages of 19 and 26.
• You have no health insurance or your insurance does not cover vaccinations. (Note: The Student Health Insurance Plan does not cover vaccines.)
• Your annual household income is less than:
• $20,800 for individuals
• $28,000 for couples
• $42,400 for a family of four

If you do not meet these criteria, you may still qualify for the vaccine program if you have special circumstances of financial and medical hardship. For exceptions based on need and financial hardship, your annual household income must be less than:

• $41,600 for individuals
• $56,000 for couples
• $84,800 for a family of four

If you think you might qualify for this program:

1. Print the application, fill it out, and sign it.
   
   Merck Vaccine Assistance Program application.
2. Bring the completed application to the UHS Cashier/Insurance Office to SSB 2.106.
3. Merck must approve your application before you can get the vaccine through their program. PLEASE TURN IN YOUR APPLICATION AT LEAST SEVEN DAYS BEFORE YOUR APPOINTMENT.
4. Bring a copy of your approved application to your appointment. You can pick it up just before your appointment in the UHS Cashier/Insurance Office.

Forms are processed quickly. You can consider your application approved unless you are told otherwise. If it is denied, a UHS staff member will contact you.

The HPV vaccine is given in three doses over several months. You will need to complete and submit a separate application BEFORE each subsequent dose.

For more information, please call the UHS Cashier/Insurance office at (512) 475-8232 or come to SSB 2.106 during regular business hours.